When to start treatment

Until recently, doctors weren’t sure of the best time to start HIV treatment. However in 2015 a large, well-conducted study demonstrated that there are advantages to starting treatment as soon as possible, with high CD4 cell counts. The study clearly demonstrated that starting HIV treatment earlier reduces the risk of serious illnesses, AIDS and death. While people sometimes worry about the side-effects of anti-HIV drugs, the study also showed that people who began HIV treatment earlier had a better quality of life than people who waited.

Other large studies have shown that taking treatment and having an undetectable viral load dramatically reduces the risk of HIV transmission. 

And other research has shown that with HIV treatment many people living with HIV can have a more or less normal lifespan.

The sooner you start to take HIV treatment, the sooner you can benefit from it.

HIV treatment guidelines, both in the UK and elsewhere in the world, now recommend that all people with HIV should take HIV treatment, regardless of their CD4 count.

If your CD4 cell count is below 200, it is especially important that you begin HIV treatment as soon as possible. The lower your CD4 cell count, the greater the risk of HIV making you ill. But even at higher CD4 cell counts, above 500, treatment you take now will protect your health, both now and in the future.

While the medical case for starting treatment as soon as possible is clear cut, the decision to start treatment rests with the person living with HIV. Before starting treatment, it’s important that you understand how it works and what it involves. You may need a little time before you feel ready to start.

NAM’s online tool Get set for HIV treatment can help you think through the practical and emotional aspects of starting HIV treatment.

Recently infected with HIV?

The six-month period after you are infected by HIV is called primary HIV infection. There is currently no clear evidence that taking treatment at this time will mean that you live a longer, healthier life. Some doctors believe, however, that taking treatment during this period may offer a unique chance to avoid damage to your immune system, especially as people have a very high viral load during this period.

If you are considering treatment during the period soon after infection, you should start as soon as possible, ideally within 12 weeks of infection with HIV. A very small number of people become quite ill during primary infection with HIV. This is often called 'seroconversion illness'. It’s possible that people who have more serious symptoms may benefit most from a course of treatment at this stage (around 48 weeks).

The potential benefits of taking treatment at this time need to be weighed up against the impact of starting HIV treatment. You may still be coming to terms with your HIV diagnosis, and not feel ready to start treatment. There is also the possibility of side-effects – treatment may reduce your quality of life at a time when HIV would not have. If your treatment doesn’t work effectively against HIV or you don’t take it in the right way, it’s possible drug resistance could develop. This could mean you have fewer drug options later.

It is recommended that you start HIV treatment during primary infection if:

  • You have an AIDS-defining illness.
  • You have a neurological condition (one that affects the brain) connected with HIV.
  • Your CD4 cell count is below 350.
  • You are worried about passing on HIV to others.

However, most people do not find out that they have HIV until months or years after infection.

Infected with HIV for over six months, but without symptoms?

Current HIV treatment guidelines in the UK recommend that treatment should be started when your CD4 cell count is around 350.  Starting treatment at this time will reduce your risk of becoming ill because of HIV, as well as of developing some other serious illnesses as well.

You are recommended to start treatment earlier (when your CD4 cell count is around 500), if you also have hepatitis C or hepatitis B, as liver disease becomes worse when the CD4 cell count is lower. There's a lot more information on hepatitis in the section Non-HIV-related illnesses - hepatitis.

It may also be a good idea to start treatment at a higher CD4 cell count if you have a higher risk of kidney or heart disease.

You can sometimes start treatment with a CD4 cell count above 350 if you would like to do so to reduce the possibility of passing HIV on to your partner. Talk to your HIV doctor about this.

Infected with HIV for over six months, and ill because of HIV?

Regardless of your CD4 cell count, doctors recommend that you start HIV treatment if you are becoming ill because of HIV, or if you have another serious illness, such as HIV-related kidney disease, heart disease or HIV-related neurocognitive (brain) illnesses. It is also recommended you start HIV treatment if you are receiving treatment for cancer and, in some cases, if you are receiving treatment for hepatitis B.

The exact timing of when you start HIV treatment might depend on what treatment you need for the other condition and the state of your health.

For example, if you also have tuberculosis (TB), the timing of your treatment will probably depend on your CD4 cell count. There are potential interactions between anti-HIV drugs and a key medicine used to treat TB. Because of this, many doctors recommend delaying treatment with anti-HIV drugs until you have been on TB treatment for at least two months. However, you may need to start HIV treatment sooner – often within two weeks of starting TB therapy – if your CD4 cell count is very low. Similarly, if you become ill with TB when you are already on HIV treatment, you may be recommended to stop taking anti-HIV drugs for the first two months of tuberculosis treatment. There's a lot more information on TB in the section Symptoms and illnesses – TB.

Diagnosed with HIV when your CD4 cell count is already low?

If your CD4 cell count is below 200, your doctor will recommend starting HIV treatment very soon (ideally within two weeks). This is because you have a risk of developing serious – and potentially life-threatening – illnesses when your CD4 count is this low.

You may also need to take small doses of antibiotics (a treatment called prophylaxis) to prevent you developing some infections. These are often called opportunistic infections [HIV-related illnesses]. Once your CD4 cell count has increased to above 200, you will stop taking the prophylaxis. If you are already ill with an opportunistic infection, you usually will start treatment for this before you start HIV treatment.

Although you may need some additional treatment and monitoring, there is a good chance that you will respond well to treatment and your immune system will start to recover.

This content was checked for accuracy at the time it was written. It may have been superseded by more recent developments. NAM recommends checking whether this is the most current information when making decisions that may affect your health.
Community Consensus Statement on Access to HIV Treatment and its Use for Prevention

Together, we can make it happen

We can end HIV soon if people have equal access to HIV drugs as treatment and as PrEP, and have free choice over whether to take them.

Launched today, the Community Consensus Statement is a basic set of principles aimed at making sure that happens.

The Community Consensus Statement is a joint initiative of AVAC, EATG, MSMGF, GNP+, HIV i-Base, the International HIV/AIDS Alliance, ITPC and NAM/aidsmap